Long Overdue: Improving Seniors Care in Canada Recommendations to address the growing needs of an aging population

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November 2018

The number of seniors in Canada is growing at a rapid pace. According to Statistics Canada, the number of Canadians age 65 and older will rise by 25% by 2036, and the number of seniors 80 years old and over will double between 2011 and 2036.1 Furthermore, for the first time in Canadian history, seniors outnumber those under the age of 14.2

The pressures caused by a growing seniors’ population is compounded by the fact that Canada’s seniors are living longer. Despite a desire to age at home many of today’s seniors are living with multiple illnesses that require 24/7 care. And when families can no longer manage to care for their loved ones at home, long-term care becomes home for Canada’s seniors.

Long-term care homes provide housing – along with physical, medical, social, spiritual and emotional support – to more than 150,000 seniors across Canada. By living longer and living at home longer, seniors are arriving at care homes at a later stage in their condition with more complex health issues and more physically frail than ever before. The prevalence of chronic conditions and cognitive impairment among residents has increased dramatically over the last decade. In 2016/17, 62% of residents were living with Alzheimer’s disease or other forms of dementia, with a third severely affected.3 Furthermore, most residents are living with multiple chronic conditions such as heart disease, arthritis, diabetes and hypertension.

Canada’s long-term care homes support people at this stage of their life, which can include extensive or complete support with everyday activities such as getting dressed, getting in and out of bed, eating and going to the bathroom.

With this in mind, the Canadian Association of Long Term Care is pleased to publish our 2019-20 Federal Budget Submission focusing on health human resources, innovation and infrastructure.

Daniel Fontaine Chair, Canadian Association of Long Term Care

1 Statistics Canada, 2015. Population Projections for Canada, Provinces and Territories. 2015-11-27 2 Statistics Canada. Age and Sex Highlight Tables, 2016 Census 3 Canadian Institute for Health Information (CIHI). CCRS Continuing Care Reporting System: Profile on Residents in Continuing Care Facilities 2016-2017. CIHI

The number of seniors 80 and over is predicted

to double between2011 and 2036.

Canadian populationaged 65 and older willrise by approximately

25% by 2036.

25%

In 2016/17, 62% of residents were living with

Alzheimer’s disease or other forms of dementia.

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Addressing the seniors care labour shortage.Changes to existing policies and programs needed to meet the critical shortage of front-line workers. In 1999, Health Minister’s from across Canada met to discuss the health human resources (HHR) challenges facing the health care system, recognizing HHR as an important issue that requires national collaboration.4 Nearly 20 years later, many of the themes that were discussed are still of critical importance today. However, there is an even greater need now to evolve the health human resources strategy in the long-term care sector to take into account changing demographics, the evolution of our health care system and the health care needs of Canadians.

In order to provide high quality care for Canada’s seniors, we require the capacity to provide that care. Attracting and retaining individuals in careers that care for Canada’s seniors has become increasingly challenging, especially when faced with the influx of seniors we know will require care for multiple and complex conditions.

A Health Human Resources Strategy for the long-term care sector would focus on the right number, mix, and geographic distribution of providers, as well as the appropriate setting for providers to deliver services. Furthermore, specifically supporting HCA/CCA/PSWs (from here on in referred to as “HCA”)5 involves structured education and continuing training to support these individuals in providing the highest quality of care, and structured governance models to affirm HCA credentials, conduct and competence.

CALTC believes that internationally recruited HCA students offer an opportunity to address – in part – the current supply crisis for trained staff in Canada. However, to do so, we need support and changes made by the federal government to address current policy to help solve any chronic labour shortages.

Students that wish to utilize a Post Graduate Workers Permit (PGWP) can only do so by participating in eligible programs from designated learning institutions. Public or private post secondary education institutions will apply to become a designated learning institution in their respective province or territory, and eligible programs must offer a program that is at least 900 hours in total length, equivalent to 8 months, according to federal requirements.6

To the general public, the term “health workers” evokes doctors and nurses. While this does not do justice to the multitude of people who make a health system work, it does reflect the public’s expectations: encounters with knowledgeable, skilled and trustworthy providers who will help them get better and who will act in their best interests.”

Working Together for Health the World Health Report 2006

World Health Organization

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4 http://www.scics.ca/en/product-produit/news-release-fpt-health-ministers-take-action-on-key-health- issues/ 5 HCA: Health Care Assistants; CCA: Continuing Care Assistants; PSWs: Personal Support Workers 6 https://www.canada.ca/en/immigration-refugees-citizenship/corporate/publications-manuals/ operational-bulletins-manuals/temporary-residents/study-permits/post-graduation-work-permit- program.html

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sThere are a number of institutions that are not classified as eligible programs under federal requirements. This is concerning for two reasons. First, the curriculums themselves being provided by these institutions are approved and recognized by the province or territory in which it is provided. And second, that same institution may also be designated learning institution - a requirement to provide a PGWP program by the federal government. With both a provincially approved institution and a provincially approved curriculum - and yet not be an eligible program for PGWP students - it is incumbent on the federal government to address a gap in the PGWP program eligibility.

To address this growing concern – especially in an sector where there is a shortage of health care workers – the Canadian Association of Long Term Care calls on the Federal Government and specifically the Minister of Citizenship and Immigration to establish a limited pilot program that allows for provincially approved and certified programs at designated learning institutions – that may be shorter than 900 hours in length – participate as an approved Post Graduate Workers Permit Program. At the conclusion of the pilot program, consideration should be given to the impact of the change that may warrant an change in federal requirements for health care based programs.

We understand that it is not plausible to believe that we can possibly solve the current HCA labour shortage through the recruitment of international students alone. However, we do believe that it is both cost-effective for governments, and appropriate to recruit international students that would attend Canadian educational institutions at their own cost. This would put them on a path towards employment in Canada and permanent residency that – in turn - helps fill a gap in our health care system.

While the challenge before us is vast, it is important to focus on both immediate solutions as well as medium-term initiatives that can help move governments and the sector in the right direction:

Develop a Pan-Canadian Health Human Resources Strategy

• CALTC is advocating that FPT Health Minister’s pick up where they left off nearly 20 years ago and through the leadership of the Federal Minister of Health, recognize the significant challenges that the long-term care sector faces in supporting our aging population, and collaborate with the provinces and the long-term care sector to immediately develop and implement a Pan-Canadian health human resources strategy.

Support International Students

CALTC is advocating that the federal government to include provincial and territorial designated learning institutions that have provincially recognized programs as eligible programs for the Post Graduate Workers Permit in order to provide students with a pathway toward citizenship and employment within the long-term care sector.

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Supporting innovation in health care and evidence-based decisions. Investments needed in new data solution: Long-Term Care Facilities (LTCF)7

To improve care in any aspect of the health care system, from a treatment plan for a patient to informing policy direction from government, decisions can be made only with the information available to a doctor, nurse, health care assistant or a policy maker. This holds true, as well, in the long-term care sector.

A vital component of the success of everything ranging from individual care planning, facility operations and government policy decision making depends on the best available information being collected at the facility level and then shared through a common mechanism across Canada to support policy makers in improving the quality of life and quality of care.

For the resident, they can expect more informed advice on their course of care.

For the residential care home, it enables health professionals and managers to make better decisions to improve care.

And, for policy-makers and researchers, developing and implementing new innovative approaches to care can only be possible by accessing information from across regions throughout Canada.

To achieve this, long-term care homes need to have access to the most up-to-date software system to collect and share data. While many homes do use some

form of system, the majority of Canadian long-term care homes do not currently use or do not have access to the most recent system due to a lack of funding. The Canadian Institute for Health Information (CIHI) does establish common reporting guidelines, collecting and reporting on data that can support the sector as a whole. They will over the coming years move away from supporting one system, RAI-MDS 2.0, in order to standardize across Canada a more efficient system, LTCF. Saving time and money with a system that requires less direct interventions from staff, LTCF provides more of the data that long-term care homes and policy makers need, while reducing information that may not be needed. Governments will need to make investments in the early stages to set the health care system up for success to provide better care in the long-term.

7 About LTCF, known as interRAI Long-Term Care Facilities Assessment System (interRAI LTCF) The interRAI Long-

Term Care Facilities Assessment System (interRAI LTCF) enables comprehensive, standardized evaluation of the needs, strengths, and preferences of persons receiving short-term post-acute care in skilled nursing facilities as well as persons living in chronic care and nursing home institutional settings. The interRAI LTCF (or previous versions) is currently used in Canada, Europe (Belgium, England, Finland, France, Germany, Iceland, Italy, Netherlands, Norway, Spain, Sweden, Switzerland), Asia (Hong Kong, Korea, and Japan), and Pacific Rim (Australia, New Zealand).

Providing the best possible care for seniors is not just a desire, but a necessary objective that the residential care sector meets every single day. Only with government investments in better infrastructure, data and Human Resources planning can seniors receive the care they need now and into the future.” Jodi Hall Executive Director, The New Brunswick Association of Nursing Homes

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Measuring Funding and Ensuring Operator Accountability

Management Information Systems (MIS) is a framework that defines the standards of reporting financial and statistical information related to the daily operations of Canadian health service organizations. Developed by the Canadian Institute for Health Information (CIHI), these national standards were created to improve effectiveness and efficiency of Canada’s long-term care and other health service organizations through better information and performance measures. A portion of facilities across Canada report MIS financial and statistical data for most health care services to CIHI for inclusion in the Canadian MIS Database.

Currently, MIS Coordinators have been appointed in most provinces to facilitate the implementation of MIS at the provincial level. However, not all jurisdictions are using the same version of MIS which is contributing to some discrepancies in reporting and making it impossible to accurately measure and compare efficiencies and best practices across the country. Due to limited capacity and lack of available funding, we believe that approximately 40% of homes are still unable to implement this important initiative.

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Mandate, fund and support the Implementation of Standardized Management Information Systems (MIS)

• That the federal government mandate a standardized system for collecting residential and financial performance data in long-term care homes as part of the Canada Health Accord agreements signed with each of the provinces and territories.

• That the federal government provide CALTC with $19.5M to ensure the full implementation of standardized Management Information Systems (MIS) across Canada for publicly funded care homes.

• The federal government, in collaboration with its provincial and territorial partners, support residential homes purchasing and implementing the standardized system to improve quality of life and quality of care for residents, and better support long-term government decision-making.

CALTC believes thatapproximately 40%

of homes are stillunable to implement

this important initiative.

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Investing in seniors housing where care is provided. Investments needed to modernize old and build new long-term care homes to increase capacity

While long-term care plays a large role in the continuum of care, viewing a long-term care home as a medical facility has been a common misconception. While clinical care is provided, a primary function of a long-term care home is to provide housing for our elderly population. This fact is not well understood and has led to our most vulnerable population not being able to access and benefit from new federal infrastructure investments, including the National Housing Strategy.

When Canadians can no longer live at home, long-term care homes offer the support and services they need, along with expertise in dementia and end-of-life care. Care homes offer around-the-clock nursing care and supervision, support with daily activities, and a safe and caring environment where people live comfortably and with dignity.

Recognizing long-term care as seniors housing where care is provided, and opening up federal infrastructure projects to include long-term care would help meet current and future demand. This will also decrease financial pressures in other parts of the health care continuum.

Physical infrastructure must be suitable for today seniors.

Changes in the volume and complexity of residents living in long-term care homes has meant significant changes in the way they are cared for. Unfortunately, the physical infrastructure where these seniors live and are being cared for has not evolved with the change in demographics.

“Older adults, including people living with dementia, require access to appropriate care when and where they need it. Care homes that are purpose built to be dementia friendly and as home-like as possible ensure better quality of life for their residents.”

Maria Howard CEO, Alzheimer Society of B.C.

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“The need for care of our elderly population is increasing while the availability of PSWs to provide for their care is rapidly decreasing. The issues are many and varied but they all come together to create a disaster in the making.”

Miranda Ferrier President, Ontario Personal Support Workers Association

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s Expand infrastructure funding to include LTC

• CALTC recommends the federal government immediately expand the eligible projects for infrastructure funding to include seniors housing which incorporates long-term care. CALTC recommends the federal government invest in the construction, renovation and retrofit of 400 long-term care homes to meet current design standards and the needs of today’s seniors, especially those living with dementia, by 2023.

(Costing based on the City of Toronto’s Long-Term Care Homes & Service Capital Renewal plan, 2015: Approximate cost to redevelop equals $83.8M per home. Approximate total cost to redevelop 400 homes would equal $33.12B (or $8.28B per year up to 2023). Federal funding could be leveraged with provincial and/or municipal investments – 1/3 federal component matched by 2/3 provincial and/or municipal = federal total contribution would be $11.04B to renovate 400 long-term care homes.)

Across Canada, a significant portion of the housing for seniors in long-term care is currently outdated or nearing the end of its functional life. Many homes were built to design standards that are not suitable for today’s seniors, featuring three- to four-bedroom hospital-like wards, shared washrooms and bathing areas, crowded dining rooms, small hallways and noisy nursing stations too close to residents’ rooms.

In comparison, new or renovated care homes feature larger, private or semi-private residences that are more reflective of a home environment. These modifications along with multiple dining rooms, wider hallways to accommodate wheelchairs and walkers, spacious common areas and updated washrooms and bathing areas allow for more privacy and better care. Modern care homes’ newly designed and increased privacy are particularly important for residents with dementia, who can become upset and aggressive when they are unable to get the personal space they need.

8 Canadian Association for Long Term Care (CALTC). CALTC Provincial Association Survey: LTC Infrastructure Needs Across Canada. 2018. 9 Ontario Long Term Care Association (OLTCA). 2018 Ontario Pre-Budget Submission: More Care. Better Care.

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Improving access to appropriate care settings for Canada’s aging population. Investments needed to improve access and alleviate pressures on the health system. Despite increased availability of home care and community services, demand for long-term care continues to surge. All jurisdictions across Canada are currently facing long-term care shortages, as existing supply of beds in care homes is not enough to meet the demands caused by the demographic shift.

It is estimated that demand for long-term care was approximately 263,000 beds in 2016.10 In Ontario alone, the wait list for long-term care reached 32,000 individuals as of June 2017, and continues to grow at a rate of 15% per year.

When a senior is unable to access long-term care, but is too ill or frail to remain at home, they occupy beds in hospitals (known as Alternate Level of Care beds) while they wait for placement.

In 2014/15 there were 407,255 reported ALC days in BC, accounting for 13% of total hospital days across the five regional health authorities.11 Furthermore, a study released in 2014 found that ALC patients occupied 33% of beds in two hospitals in New Brunswick, of whom 63% had been diagnosed with dementia, with the average length of hospital stay for all ALC patients being 380 days.12

This is not a suitable place for seniors who require specialized care and supports that long-term care homes offer. Not only is it unsuitable, it also puts additional pressures and financial strains on other parts of the health care system, particularly the acute care system, and is an increased cost to taxpayers.

In Canada, the cost of an ALC bed can reach up to $1,800 per day, compared to approximately $200 per day in long-term care. If seniors occupying ALC beds in hospitals were able to access long-term care, the savings to our health care system would equal 2.3 billion annually.13

The cost of an ALC bed can reach up to $1,800 per

day, compared to approximately $200 per day in long-term care.

10 Conference Board of Canada. Sizing Up the Challenge. Meeting the Demand for Long-Term Care in Canada. 2017. 11 BC Care Providers Association (BCCPA). BCCPA Budget Submission: 2017. It’s About…Time. Improving Quality of Life for BC Seniors. 12 McCloskey R, Jarrett P, Stewart C, et al. Alternate level of care patients in hospitals: What does dementia have to do with this? Can Geriatr J. 2014 Sep 5;17(3):88–94. 13 CMA. CMA Submission: The need for health infrastructure in Canada. 2013.

The estimated demand for long-term care was

approximately 263,000 beds in 2016.

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sCommit funding to build new long-term residences

• To meet current and future demand for long-term care, CALTC recommends the federal government increase capacity by committing to funding the addition of 42,000 new long-term care resident beds across the country by 2023.

(Costing based on the Conference Board of Canada’s 2017 report: 10,500 beds per year x $320,000 per resident bed = $3.36B per year. Total cost to add 42,000 resident beds by 2023 = $13.4B. Federal funding could be leveraged with provincial and/or municipal investments – 1/3 federal component matched by 2/3 provincial and/or municipal = federal total contribution would be $4.48B to add 42,000 seniors’ resident beds by 2023.)

About the Canadian Association for Long Term Care

CALTC is a national organization comprised of provincial associations and long-term care providers that deliver publicly-funded health care services for seniors across Canada. CALTC members also represent care providers delivering home support services and care for younger disabled adults.

CALTC members represent care providers responsible for the employment of Canadians and delivering quality care to Canada’s most vulnerable residents each day.

Our purpose is to share information, insights and best practices on current and emerging long-term care issues, collaborate to address issues and opportunities that impact long-term care and take common positions on issues that have broad impact on participating associations.

caltc.ca | @CALTC_CA